InsightFHIR for Payers

Payers are faced with a meaningful opportunity and a challenge at the same time. Data analytics (the opportunity) has the capabilities to turn a deluge of disparate clinical, financial, network and member information (the challenge) into relevant, actionable intelligence.

We’ve been hot on FHIR for some time and, recently, we talked to a host of industry sources and clients to see what others think of each standard and their plans for the future.

This Point of View gives our top-line views when comparing HL7 against FHIR, as well as our recommendations for near-term actions around your API architecture pursuits.

Health plan sales professionals need in-the-moment knowledge and analytics in order to drive compelling conversations and demonstrate, on-the-fly, how your products can have a measurable impact on an organization’s costs and members’ access. We’ve seen how creating hooks into member data like cost, claims and geography – and presenting that data in interactive visualizations – is changing the business of “selling health insurance.”

Data feeds via HL7 or FHIR can be turned into a host of robust sales tools, including dashboards that display solution snapshots and potential savings, provider and network mapping, live product cost comparisons, and the ROI of value-based and member engagement programs.

Member Engagement:

While data science requires accurate, malleable data sources to offer potential insights, member engagement is all about focusing analysis around the member experience and how buying your plan’s insurance can improve health and quality of life.

Where FHIR offers a major advantage is the capability to unlock data and information stored on proprietary systems through a non-proprietary interface. This can be crucial for payers to take their in-house or custom-designed data architecture – for their member portal or telemedicine program, for example – and connect that to many user channels. This could mean that your member portal can accept data streams from member wearables, medical-grade apps or even other popular health and wellness apps.

Care Management:

Care plans have, traditionally, been manual and static in paper form. Today, however, EMRs have moved care management towards a whole new world, including template- and evidence-based care plans.

Powered by HL7 and FHIR, care management across all aspects – disease management, chronic care management, care coordination and wellness – has the potential to be revolutionized.

FHIR, in particular, offers more flexible interoperability (e.g. tailored data feeds, microservices) where care management can be shared across disparate data sources, technologies, physical locations and care channels. Imagine a payer that sets up their ACO to have interoperability across their service region where care management, community-based services, non-profit organizations and the entire clinical care team can access, share and collaborate on the same care plan around the member and his or her family caregivers.

Payer-Provider Collaboration:

Payer-provider collaboration and integration brings with it an opportunity for HL7/FHIR to shine. It can be key to making such relationships work. Payer-provider organizations can send real-time ADT data amongst all facilities, generate automated authorization requests, send real-time lab results and real-time patient encounter summaries via C-CDA. What’s more these feeds can improve latency in clinical data movement, clinical data accuracy and better matching among disparate clinical, financial and enterprise systems, improving the overall patient and member care experience.

Additionally, in a population management ecosystem, payers and providers can work together around specific chronic conditions more tightly because of reliable and transparent data across organizations. These organizations can have more confidence as they create outcomes-based risk sharing agreements and value-based models.

Strategic Planning:

Throughout the payer organization, member data is invaluable to preempting short- and long-term trends. Whether the effect of these trends is financial, regulatory, consumer, cultural or medical, having all the right data beyond claim information gives health plans a competitive edge. HL7 and, in particular, FHIR, offer payers the opportunity to do more predictive analysis based on a wider array of relevant data points.

Timely data analytics is key to driving proactive business decisions. Through innovations in interoperability, payers can have more real-time analytics to drive strategic goals, as well as engender transparency through single-source data truths. More timely and accurate data feeds from dissimilar sources provides a unique opportunity for payers to have a new level of confidence in the intelligence behind their performance planning and monitoring efforts.

Innovative health plans are exploring interoperability technology that will not only help them control costs and offer the right type and level of care to members, but they also want to build an edge in a competitive marketplace. Standards, like HL7 and FHIR, offer unprecedented access to and strategic use of valuable structured and unstructured data.

SDLC Partners is poised to help payers design an approach that can maximize HL7 and FHIR for your forward-looking objectives. Whether your focus is on care management, member engagement, payer-provider collaboration or sales and strategic development, we can help.

Want to talk to Chris? He welcomes a tech-talk around the possibilities of HL7 and FHIR. Reach him at cweirup@sdlcpartners.com.